Claims Specialist

• Provides advanced technical review of all types of claims in accordance with Company guidelines
• Performs technical review and analysis of all types of claims to ensure accuracy and adherence to prescribed procedures and plan guidelines
• Coordinates appeals through research and documentation; generates denial or approval letters
• Coordinates predetermination reviews and performs analysis to determine benefit allowance and benefit category
• Processes refunds, voids, and overpayments, including related claim adjustments
• Processes time loss claims and communicates with local union offices, medical service providers, employers, and members
• Reviews and interprets new benefit plans or plan changes

Claims Technical Review Specialist

• Identify and obtain statements from insureds, vendors and witnesses.
• Conduct phone and/or field investigations to determine coverage and damages and differentiate between allegations and facts in each loss.
• Communicate and interact with a variety of individuals.
• Explain benefits, coverages, and claims process either verbally or in writing in compliance with regulatory and statutory requirements.
• Recognize and appropriately address moderate complexity coverage issues.
• Evaluate and determine claim values upon receipt and assessment of property damage data.
• Negotiate within settlement authority with insureds to resolve first claims.
• Update database production reports, and document and update claim files via company systems, i.e. CACS, HUON, HOC, GUIDEWIRE, etc.
• Control expenses for areas of responsibility.
• Verify and interpret / resolve coverage by gathering necessary information to ensure policy applicability.
• Objectively discern and address issues that may be questioned in audit.
• Coordinate with internal and external departments as required.
• May attend and participate in legal proceedings.
• Respond quickly and effectively to customer needs and problems.

Senior Property Adjuster

• The Claims Senior Casualty Adjuster handles moderate to high complexity claims involving material damage, property and/or liability lines of insurance written by the Interinsurance Exchange in compliance with all regulatory and statutory requirements.
• Conduct phone and/or field investigations to determine liability and damages.
• May attend and participate in legal proceedings.
• Identify and obtain statements from insureds, claimants and witnesses.
• Communicate and interact with a variety of individuals including insureds and claimants.
• Explain benefits, coverages, fault and claims process either verbally or in writing in compliance with regulatory and statutory requirements.
• Recognize and appropriately address moderate complexity coverage issues.
• Evaluate and determine claim values upon receipt and assessment of property, bodily injury and liability data.
• Negotiate within settlement authority with insureds and claimants to resolve first and third party claims.
• Update database production reports, and document and update claim files via company systems, i.e. CACS, HUON, HOC, GUIDEWIRE, etc.
• Control expenses for areas of responsibility.
• Verify and interpret / resolve coverage by gathering necessary information to ensure policy applicability.
• Coordinate with internal and external departments as required.
• Respond quickly to customer needs and problems.
• Independently resolve claims within authority level.

Senior Casualty Adjuster

• Effectively evaluates, and manages liability, property, auto, general liability claims, and employment claims in compliance with state regulations
• Attends legal hearings, settlement conferences, mediations to provide testimony and monitoring proceedings
• Maintains claims files and records to document actions and ensuring compliance with participating policies and mandated legal requirements

• Process dental claims, pre-authorizations, and referrals accurately and within required turnaround times.
• Perform high-volume data entry while maintaining accuracy and efficiency.
• Review and determine benefits according to plan guidelines and processing requirements.
• Maintain knowledge of service level agreements (SLAs) and applicable state regulations.
• Meet or exceed established production and quality goals.
• Support a positive, collaborative team culture.
• Follow established procedures, policies, and safety protocols.
• Perform additional duties and special projects as assigned.

Claims Referral Specialist I

• Review and process claims documents
• Collaborate with team members to resolve claim issues
• Maintain accurate records and documentation
• Communicate with clients regarding claim status and updates

Claims Referral Specialist II

• Manage customer inquiries via phone and email
• Provide support for product-related questions
• Collaborate with internal teams to resolve issues

Claims Referral Specialist III

• Manage workers compensation claims caseload
• Reviewing new claims and ensuring all required information is complete
• Making initial contact and responding promptly to inquiries
• Processing incoming mail and handling relevant documentation
• Managing medical requests and coordinating with providers
• Evaluating claims for closure and decision making

Claims Associate II – Workers Comp

• Responsible for ensuring timely and accurate billing is submitted to the appropriate third-party payer.
• This role is responsible for PPCCC’s geographic area (Thousand Oaks to San Luis Obispo) health center billing.
• Validates charges from pending charges report, with EHR and PM systems within NextGen.
• Creates claims into Rosetta holding tank for processing to Claim Remedy.
• Identifies issues that need improvements and communicates with Center Director or Clinician.

Temp Claims Specialist

Senior Claims Field Property Adjuster

• Investigate and resolve claim rejections, denials, and payer edits identified before or after claim submission
• Review claim history, payer correspondence, medical records, authorizations, and supporting documentation to determine the cause of claim issues
• Correct billing, coding, demographic, authorization, and insurance-related claim errors as appropriate
• Process claim corrections, adjustments, resubmissions, and reconsideration requests in accordance with payer guidelines
• Perform payer research and communicate directly with insurance carriers to resolve claim processing issues
• Monitor assigned work queues and ensure timely resolution of outstanding claims
• Escalate complex reimbursement, coding, or compliance issues to senior team members
• Partner with A/R and Denials Management teams to resolve denied and underpaid claims
• Assist in preparing appeal documentation and supporting materials for denied claims
• Identify recurring denial patterns and communicate findings to the Senior Claims Resolution Coordinator
• Maintain accurate documentation of denial resolution activities and payer communications
• Support efforts to reduce preventable denials and improve reimbursement outcomes
• Work closely with the pre-billing team to identify and correct claim issues prior to submission
• Review claims for completeness and compliance with payer billing requirements
• Verify insurance information, authorizations, referrals, diagnosis coding, procedure coding, and modifier usage
• Collaborate with coding and clinical teams to obtain information needed for claim resolution
• Assist with reducing claim holds and billing delays
• Participate in routine claim quality reviews and internal audit activities
• Ensure claim corrections comply with payer regulations, organizational policies, and billing guidelines
• Support Revenue Integrity initiatives through accurate claim review and documentation
• Maintain knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial payer requirements
• Adhere to HIPAA, CMS, and organizational compliance standards
• Maintain detailed documentation of claim investigations, resolutions, payer communications, and follow-up activities
• Track assigned workloads and resolution outcomes
• Assist with compiling information for denial trend reporting and operational reviews
• Provide feedback regarding workflow issues contributing to claim errors or payment delays
• Assumes other responsibilities as appropriate to the position and organizational needs

Claims Resolution Specialist

• Completes classroom training introducing workers’ compensation claims handling strategies, medical terminology, and legal concepts.
• Learns skills such as investigative and persuasive communication, negotiation, decision-making, and strategic planning. Learns to review and interpret medical records.
• Conducts and directs the investigation of reported claims to determine coverage, compensability and severity and to gather all other relevant information, including making three-point contact telephone calls.
• Calculates appropriate reserves for each claim and ensures that reserves are adjusted as needed per authority guidelines.
• Develops and updates a plan of action for the successful resolution of each claim.
• Assigns appropriate tasks to a Claims Assistant and/or Claims Clerical Assistant and ensures they are performed correctly and efficiently.
• Reduces fraud through early identification and escalation.
• Communicates effectively with individuals outside the company, including clients, medical providers, and injured workers.
• Prepares timely and accurate settlement recommendations (within designated authority parameters) and effectively negotiates the settlement of claims.
• Ensures that the actions of all other professionals involved in managing a claim, including attorneys, nurse case managers, and investigators, are coordinated to achieve a successful resolution of the claim.

Claims Examiner – Trainee

• Successfully completes classroom training introducing workers compensation claims handling strategies, medical terminology, statutory requirements, and investigative skills.
• Conducts initial investigation of reported claims to determine coverage, compensability, severity, and gather all other relevant information via three-point contact telephone calls.
• Calculates appropriate reserves for each claim and ensures that reserves are adjusted as needed per authority guidelines.
• Develops and updates a Plan of Action for the successful resolution of each claim.
• Makes prompt, sound decisions on issues that arise based on the best information available, ensuring that work is performed in accordance with Company guidelines and applicable statutory requirements. Timely escalates issues/red flags to Supervisor.
• Ensures benefits due injured worker are calculated and issued appropriately in accordance with legal requirements including the issuance of appropriate notices and filings.
• Fosters a positive and close working relationship with internal and external partners, including Call Center, Medical Management, Special Investigations, and Indemnity Adjusting Staff.

Claims Adjuster, Spanish Fluency Preferred

• Manages an inventory of moderate to high complexity and exposure commercial claims by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits.
• Provides exceptional customer service by interacting professionally and effectively with insureds, claimants and business partners, achieving quality and cycle time standards, providing regular, timely updates and responding promptly to inquiries and requests for information.
• Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters, estimating potential claim valuation, and following company's claim handling protocols.
• Conducts focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim.
• Establishes and maintains working relationships with appropriate internal and external work partners, suppliers and experts by identifying and collaborating with resources that are needed to effectively resolve claims.
• Authorizes and ensures claim disbursements within authority limit by determining liability and compensability of the claim, negotiating settlements and escalating to manager as appropriate.
• Contributes to expense management by timely and accurately resolving claims, selecting and actively overseeing appropriate resources, and delivering high quality service.
• Identifies and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Recovery or SIU resources for further investigation.
• Achieves quality standards on every file by following all company guidelines, achieving quality and cycle time targets, ensuring proper documentation and issuing appropriate claim disbursements.
• Maintains compliance with state/local regulatory requirements by following company guidelines and staying current on commercial insurance laws, regulations or trends for line of business.
• May serve as a mentor/coach to less experienced claim professionals
• May perform additional duties as assigned.

Complex Claims Specialist – Professional Liability, Real Estate

• Effectively manages a caseload of indemnity claim files, including very complex and litigated claims.
• Initiates and conducts investigations in a timely manner.
• Determines compensability of claims and administers benefits based upon state law and TRISTAR Best Practices for claim handling.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel and participates in litigated matters.
• Communicates with claimants, attorneys, providers, and vendors regarding claims issues.
• Works in an organized and proactive manner.
• Computes and sets reserves within Company guidelines.
• Settles and/or finalizes all claims and obtains authority as designated.
• Maintains a diary system for case review and documents file to reflect the status and work being performed on the file, including a plan of action.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Conducts file reviews as scheduled by the client and management.
• Identifies and reviews claims for the Apportionment assignment.
• Identifies and investigates subrogation potential and pursues recovery.
• Identifies claim standard criteria for excess reporting and reimbursement.
• Assists with State Audit and reporting responses.
• Mentors less experienced Examiners.
• Other duties as assigned, including claims management of other jurisdictional workers’ comp claims. Adheres to all TRISTAR company policies and procedures.

Claims Examiner III

• Independently manage a caseload of California workers' compensation claims from assignment through resolution
• Investigate claims, evaluate compensability, and determine appropriate claim handling strategies
• Review coverage, liability, medical documentation, and claim exposure in accordance with California regulations
• Establish and manage reserves based on claim exposure and ongoing developments
• Manage complex indemnity claims, including litigated files and settlement negotiations
• Coordinate with defense counsel, medical providers, employers, and other stakeholders throughout the claims process
• Monitor claim progress, maintain accurate diaries, and ensure timely follow-up on all assigned files
• Coordinate return-to-work efforts and support positive claim outcomes
• Identify fraud, subrogation, and cost containment opportunities when appropriate
• Maintain complete, accurate, and timely documentation within the claims management system
• Provide guidance and claim recommendations on complex files as needed
• Perform additional duties and projects as assigned

Senior Workers Compensation Claims Examiner

• Reports directly to the unit Claims Supervisor
• Responsible for effectively managing to conclusion an assigned inventory of claim files
• Perform a three-point contact on all new losses within 24 hours of receipt of the claim
• Thoroughly and accurately gather evidence regarding ongoing case facts
• Assure that all assigned indemnity claims have an up to date plan of action
• Form a partnership with the medical case manager to maximize early return to work potential
• Initiate the referral to the SIU of cases with suspected fraud
• Aggressively pursue subrogation from culpable third parties
• Assure that the claim file is handled in accordance with applicable statutes
• Review and approve all vocational rehabilitation plans
• Establish, monitor, and adjust monetary case reserves when warranted
• Review all medical bills for appropriateness prior to referral for payment
• Exhibit and maintain a courteous and helpful attitude
• Respond to telephone messages and inquiries within 24 hours

Workers Compensation Claims Adjuster II

• Reports directly to the unit Claims Supervisor
• Provide technical backup in the absence of the Claims Supervisor
• Manage an assigned inventory of claim files
• Perform a three-point contact on all new losses
• Document ongoing case facts and information for compensability
• Ensure up to date plan of action for indemnity claims
• Partner with medical case manager for early return to work
• Refer cases with suspected fraud to SIU
• Pursue subrogation from culpable third parties
• Review and approve all vocational rehabilitation plans
• Monitor and adjust monetary case reserves
• Review medical bills for appropriateness prior to payment referral
• Maintain a courteous and helpful attitude and project a professional image

Workers Compensation Claims Adjuster, III

• The Claims Senior Casualty Adjuster handles moderate to high complexity claims involving material damage, property and/or liability lines of insurance written by the Interinsurance Exchange in compliance with all regulatory and statutory requirements
• The primary functions include liability investigation, coverage evaluation, negotiation strategies and claims resolution of moderate to high complexity claims
• Employs discretion and independent judgment to ensure compliance with state and federal law, and with established company, technical, and customer service best practices
• Under general supervision, works within specific limits of authority to resolve claims
• Conduct phone and/or field investigations to determine liability and damages
• May attend and participate in legal proceedings
• Identify and obtain statements from insureds, claimants and witnesses
• Communicate and interact with a variety of individuals including insureds and claimants
• Explain benefits, coverages, fault and claims process either verbally or in writing in compliance with regulatory and statutory requirements
• Recognize and appropriately address moderate complexity coverage issues
• Evaluate and determine claim values upon receipt and assessment of property, bodily injury and liability data
• Negotiate within settlement authority with insureds and claimants to resolve first and third party claims
• Update database production reports, and document and update claim files via company systems, i.e. CACS, HUON, HOC, GUIDEWIRE, etc.
• Control expenses for areas of responsibility
• Verify and interpret / resolve coverage by gathering necessary information to ensure policy applicability
• Coordinate with internal and external departments as required
• Respond quickly to customer needs and problems
• Independently resolve claims within authority level

• Collaborate as a member of the Epic analyst team, providing developer-level support
• Apply deep understanding of professional billing and claims applications to optimize system performance
• Troubleshoot and resolve break/fix issues within the PB and Claims modules
• Implement application enhancements to improve efficiency, compliance, and user experience
• Work effectively within an established team structure, contributing to shared goals
• Partner with the manager to prioritize tasks and deliverables

Claims Specialist jobs in California

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Claims Technical Review Specialist

Senior Property Adjuster

Senior Casualty Adjuster

Claims Specialist

Claims Referral Specialist I

Claims Referral Specialist II

Claims Referral Specialist III

Claims Associate II – Workers Comp

Temp Claims Specialist

Senior Claims Field Property Adjuster

Claims Resolution Specialist

Claims Examiner – Trainee

Claims Adjuster, Spanish Fluency Preferred

Complex Claims Specialist – Professional Liability, Real Estate

Claims Examiner III

Senior Workers Compensation Claims Examiner

Workers Compensation Claims Adjuster II

Workers Compensation Claims Adjuster, III

Senior Casualty Adjuster

Epic Certified PB, PB Claims Analyst